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) S.S.


I,___________________________________________________, of legal age, and residing at

___________________________________________________________, after being duly sworn to in
accordance to law, depose and state that:

1. That I am the registered and lawful owner of a certain motor vehicle described as follows:

MAKE & TYPE : _______________________________

MOTOR NO. : _______________________________
CHASSIS NO. : _______________________________
PLATE NO. : _______________________________

2. I am presently applying for registration/reconstruction/transfer of the aforesaid motor vehicle


3. In my capacity _______________________________________________________, I hereby

unconditionally warrant the absolute title and ownership over the above described motor
vehicle, and I hereby declare that the same is free from any liens, suits, claims or encumbrances
whatsoever, or any matter which may prove adverse thereto;

4. I hereby release the Land Transportation Office, its officials, staff and personnel from any suits,
claims or liabilities which may arise from the approval of the said application for motor vehicle
registration or any process or matter pertinent thereto and in the event of any suit, claim or
liability, I hereby undertake to defend such title, as well as assume and satisfy any such suits or
claims resulting therefrom, without cost, charge or liability whatsoever accruing to the Land
Transportation Office, its officials, staff and personnel;

5. I am executing this affidavit to attest to the truth of the foregoing facts, for warrant the title and
ownership of the above-described motor vehicle, and for whatsoever legal intents and purposes
it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ___________ day of

_______________________ at ______________________.


SUBSCRIBED AND SWORN to before me this ____________ day of

____________________ affiant exhibiting to me his/her Community Tax Certificate No.
____________________ issued on ________________________ at _________________________.

Doc. No. ___________

Page No. ___________
Book No. __________
Series of ___________